HARLESTON, W.Va. — When the Republicans’ first effort to repeal and replace the Affordable Care Act collapsed earlier this spring, Mary Aldred-Crouch, an addiction counselor here, saw that failure as a victory. “It was Snoopy dance time,” she said.

But the Republicans didn’t give up. And when the House passed a more conservative version of the GOP health plan last week, Aldred-Crouch felt her anxiety spike. West Virginia, like other states afflicted by the opioid crisis, lately has seen so many more patients with drug addiction find treatment.

The new bill threatens to destroy that progress, Aldred-Crouch and other counselors say.

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“When I heard it passed, I about fell out of my chair,” she said, noting that the three House members from West Virginia — all Republicans — backed the measure. “I am so disappointed in them, I can’t see straight. You just torched the health benefits of 200,000 West Virginians, and in the middle of an [opioid] epidemic.”

Republicans have framed their bill as a way to give patients more freedom in their insurance choices, allowing them to buy plans that fit their needs instead of being mandated to buy coverage for services they would never use. But the bill’s huge cuts to Medicaid could cause millions of low-income people to lose coverage. The bill also gives states the flexibility to redefine which “essential benefits” insurance plans must cover — and some could choose to make mental health and addiction coverage optional.

That’s a harsh blow for the recovery community, which was just starting to feel — at last — as though it had the elements in place to at least start combating the epidemic.

It required the problem to fester into a full-blown crisis, killing more than 30,000 people a year, to grab the public’s attention, but policymakers and even presidential candidates had begun putting forward opioid plans. States were expanding access to medication-assisted treatment, needle exchanges, and overdose antidotes. Under the Affordable Care Act, hundreds of thousands of newly insured people were able to seek help and have it paid for. The law’s Medicaid expansion provided an estimated 1.3 million people with substance abuse or mental health care.

President Trump, both in the campaign and in office, had signaled that the availability of such services would only grow during his administration.

Now, counselors fear that by reducing the number of insured, the GOP health plan could inevitably make it harder for people in need to get help.

“We’ve finally gotten people to want to come in and recognize the need for them to come in, and we’ve made those services available to people and made them affordable, and now we’re going to take them away,” said Gerry Schmidt, the president of the Association for Addiction Professionals, also known as NAADAC.

Handouts given out during the annual alcohol and drug abuse advocacy day in March at the West Virginia State Capitol in Charleston.Sam Owens for STAT

Senate Republicans have already said they are going to rewrite the House health plan, so the details of a final bill remain to be seen.

But as passed, the House bill would roll back the Medicaid expansion that 31 states, including West Virginia, took advantage of under the ACA and cap federal contributions to the Medicaid program beyond the expansion. Millions of people would be expected to lose their coverage, and those who maintain some sort of plan might find it more expensive to get substance abuse treatment.

Those were the possibilities that alarmed Aldred-Crouch as she briefed the West Virginia Association of Alcoholism and Drug Abuse Counselors at the statehouse back in March, when the first version of the GOP bill was circulating. As she spoke, earning nods of approval, others passed around papers with contact information for the West Virginia congressional delegation and suggestions for what to tell lawmakers.

Aldred-Crouch’s key message: get involved. Call your representatives and senators. Tell them about yourself — and that you vote.

“The biggest issue we face today is the feds,” she said at the counselors’ annual advocacy day. “If that passes, we’re in deep doo-doo.”

Then the advocates spread through the massive marble rotunda on the second floor of the Capitol, hoping to snag a few minutes with state lawmakers.

“If they defund it, addicts are not going to stop being addicts,” Aldred-Crouch said about possible Medicaid cuts. She argued that restricting access to treatment would only lead to more expenses for criminal justice, family services, and round after round of emergency department visits.

“If nothing else, you’re going to be paying for public funerals,” she said.

The bill’s possible impact on substance abuse treatment has a particular significance here in West Virginia and in places like neighboring Kentucky and Ohio. All three states have been walloped by the opioid crisis, expanded Medicaid under Obamacare, and threw their support to Trump in the election.

Now, counselors say, some people in treatment, many of whom were drawn to Trump for his economic message and pledge to reinvigorate the coal industry, are starting to ask if they could really lose their coverage. As a candidate, Trump had promised to provide care for everyone and pledged not to cut Medicaid. What’s more, voters figured if Trump brought better jobs, then they wouldn’t have to worry about affording health care.

More moderate Republicans have been voicing concerns about the Medicaid cuts and access to addiction treatment for months. Among them: Ohio Governor John Kasich and Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia.

That’s not to say Republicans in this region are uniformly anxious. In Kentucky, Senate Majority Leader Mitch McConnell, whose state has seen the biggest drop in its rate of uninsured residents since Obamacare was enacted, has campaigned in support of the bill, and will be leading the Senate’s efforts to pass a replacement measure.

And even among the public, the threat of losing insurance is not on everyone’s radar here, many counselors pointed out. Many people on Medicaid have too many other things to worry about than the latest back-and-forth in Congress.

“Their focus is on their family, their focus is on their day-to-day life,” said Heather Sharp-Spinks, a social worker and addiction counselor in rural Pocahontas County.

Even with Obamacare, the current system is by no means providing everyone with the treatment they want, the counselors acknowledged. People who have private insurance are paralyzed by their high deductibles. Waiting lists are still the norm for recovery programs. There aren’t enough clinics or providers, and the ones that are out there are already strapped.

A pin on the lapel of Mary Aldred-Crouch, president-elect and public policy chair of the West Virginia Association of Alcoholism and Drug Abuse Counselors.Sam Owens for STAT

Patty Deutsch, a counselor in private practice in Charleston, said she knows doctors who offer medication-assisted treatment who won’t see Medicaid patients because the program reimburses clinicians at such low rates. She works out sliding-scale payments for people on Medicaid — they pay what they can, when they can — so she doesn’t have to deal with the hassle of being reimbursed.

“We are dealing with people who are on the edge of death,” she said. “The people we treat, many of them, most of them, want to get better. They just don’t have the tools to do it.”

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The answer was not to cut funding and coverage further, the counselors said. They are not only worried about people trying to find treatment in the future, but also those who are in recovery now, in the midst of months- or years-long medication-assisted treatment and counseling programs.

“They are remaining clean and sober because of the treatment they get,” said Joan Englund, the executive director of the Mental Health and Addiction Advocacy Coalition, an Ohio group. “If that’s taken away, their recovery is in peril.”

Before the Medicaid expansion, Aldred-Crouch used to have someone else listen to her voicemail messages because she couldn’t handle hearing more people telling her they were going to die with a needle in their arm if they couldn’t get help, only to have to add them to waiting lists that could take several years to climb.

The expansion hasn’t solved that problem, she said, but it has at least helped somewhat.

“In early recovery, these folks are like a country music song,” she said. “The house is gone, the wife is gone, the job is gone, even the dog is gone. Medicaid is the only option, as long as the expansion remains in place.”

The vast majority of addiction rehab facilities in the US are sleep-away delivery systems for 12 step ideology. Not only are these facilities modeled on the 12 steps, using 12 steps literature (often banning any other reading material), but they tell their recently-graduated customers to go to the 12 step meetings near their homes upon release.

If people want to pay for 12 step summer camp, that’s one thing, but forcing insurers to pay for people to be given room & board, and a place to sit around convincing each other how “powerless” they are over alcohol, drugs, gambling, sex, shopping, being the grandchild of people who drank, whatever, seems a good recipe for driving up insurance premiums for the insured who are not so “powerless.”

And I have to ask, if the 12 steps are so great, why are the multiple, free meetings available in every part of this country not enough to cover the needs of those who want to participate in this religion (and it has been found by 3 circuit court decisions to be a religion that cannot be forced upon inmates)? Why do we also need these facilities, and on top of that, multiple federal agencies centered on the addiction/recovery sin-and-redemption narrative of the 12 steps? And on top of that, we have dozens of federal and state agencies centered on using the full weight of federal and state governments, including incarceration, disrupting education and career paths, civil forfeiture of all possessions, and pressuring families to enact “tough love” ostracizing, in service of the war on drugs/prohibition – not to mention the government convincing Hollywood to put 12 steps messages & storylines into TV shows & movies.

And after all this federal effort and spending $51 billion/year, the feds are doing everything they can to convince the public we are in the midst of an opioid epidemic.

All of those folks that call patients with health care problems drug addicts are involved with black market manufacture, sales and distribution of street drugs. All drugs should be over the counter, and available with out a prescription at any and all drug stores. Our Senators, Congressmen, Mayors, Governors, city council, and Police are all involved in the million dollar per week paycheck from having drug illegal. That is why legislation is there to call patients CRIMINALS (DRUG ADDICTS) and Legislation to MAKE DRUGS illegal, why, so that patients with health care issues have to go to street drugs to keep working and to stay alive. And so the rich can make more money in black market sales, to the tune of millions of dollars per city per week. All in the hands of our leaders and authorities.
STOP DRINKING THE KOOL-AIDE, why does a congressman go into congress and become a millionaire in 2years.??? Black market sales. Legalize all drugs and the problem will be solved.

Fran, You’re so right. The feds are putting out these numbers about opiate/opioid deaths increasing. If they really wanted to reduce the numbers of deaths, we’d do what Portugal did in 2001 and end prohibition. The feds and the drug warriors (like the 12 steppers) are using these deaths in a cynical fashion to scare the public into going along with depriving law-abiding pain patients of opioid meds they need to work, keep house, care for family and just generally participate in their communities, instead of being stuck in bed or killing themselves.

Pain patients are being depicted as whiny cowards and/or addicted criminals pretending to have health problems to get their hands on illicit drugs. It’s disgusting.